Why Integrate Behavioral Health?

Nearly 1 in 6 California adults has a mental health need, and approximately 1 in 20 suffers from a serious mental illness that makes it difficult to carry out major life activities. (California Health Care Foundation, www.chcf.org, July 2013)

On January 1, 2014, the State Department of Health Care Services broadened Medi-Cal services to include mental health and substance abuse support. These new benefits require enhanced collaboration between Medi-Cal managed care plans and community-based safety net providers to ensure access to and coordination of services.

Developing and implementing a model to improve whole person care for patients with mild to moderate to severe mental health conditions requires investing in system-wide care coordination planning processes; documenting processes for collaborative treatment planning; health information technology and programming to link disparate electronic health records; and improved data analytics across the system.


What We Do

Aliados Health convened two cross-system Care Collaboration Task Forces comprised of county behavioral health agencies, community health centers, other community-based behavioral health providers (Yolo County), Partnership HealthPlan and Beacon Health Options. These task forces began discussion around interoperability between electronic health records, developing a resource guide to help understand the current data sharing requirements, shared screening tools, identified workforce issues – i.e. the lack of psychiatrists in the communities and the need for training.

Several learning collaborative sessions were convened where models of care at 5 health centers were shared, and collaboration and prevalence data were reviewed with partners.  Additionally, a series of three trainings were offered, directed primarily at helping increase understanding of behavioral health care for primary care providers and what level of help they could offer:

  • Assessing Behavioral Health Conditions
  • Managing Behavioral Health Conditions with a focus on Psychotropic Medications
  • Trauma Informed Care

Moving forward, we are looking to document the participating health centers’ existing care coordination and care transitions processes and identify opportunities to improve transitions of care between behavioral health providers; develop a universal release of health information and continue growth of the use health information exchange.

Who We Serve

Medi-Cal Patients from our participating health centers.


This project was generously funded by the Blue Shield of California Foundation.

Project Timeline

July 1, 2014 – December 31, 2016



The project team will follow a cohort of patients with complex needs pre and post implementation of the training program. In addition to tracking process measures, the project team will examine how the training program impacted patient outcomes over time.

Process Measures Outcome Measures
SAMHSA 6 Levels of Integration Utilization Data
Social Determinants of Health Indicators (PRAPARE tool)


Health Centers:

  • Alexander Valley Healthcare
  • Alliance Medical Center
  • Coastal Health Alliance
  • CommuniCare Health Centers
  • Jewish Community Free Clinic
  • Marin Community Clinics
  • OLE Health
  • Petaluma Health Center
  • Planned Parenthood – Northern California
  • Sonoma County Indian Health Project
  • Santa Rosa Community Health Centers
  • West County Health Centers
  • Winters Healthcare Foundation

Strategic Partners:

  • Blue Shield of California Foundation
  • Partnership HealthPlan of California
  • Beacon Health Options
  • Sonoma County Behavioral Health


For more information, please contact Stephanie Chandler


  • HRSA HCCN Grant
    • Social Determinants of Health
    • Patient Centered Medical Home (a model of care)